Issues in patient management

Journal of Family Practice, June, 2005 by Goutham Rao, Richard H. Jr. Davis, David A. Peura, Wendy L. Wright

INTRODUCTION

Heartburn is highly prevalent and can vary in frequency and severity. For some patients, it is merely an occasional nuisance. For others, however, it is chronic and disabling.

Among clinicians, frequent heartburn is widely acknowledged to be the most common symptom of gastroesophageal reflux disease (GERD). The purpose of this roundtable discussion was not to provide a comprehensive overview of the diagnosis and management of GERD. Rather, it was to formulate a rational, cost-effective approach to the treatment of heartburn that would be applicable to primary care providers in a variety of practice settings while keeping in mind the need to satisfy patient expectations about improvement of symptoms.

DISCUSSION POINT 1

HEARTBURN: WHAT IT IS AND WHAT IT IS NOT

Rao: The question of what is not heartburn is important because patients describe a wide variety of symptoms as "heartburn." Descriptions of severity also vary. Some people come in with disabling symptoms. Others mention a "bit of indigestion." What exactly do patients mean when they complain of heartburn? What is the spectrum of symptomatology?

Peura: There are 2 characteristic symptoms: (1) a burning discomfort centered in the chest that radiates in an upward direction and (2) a mechanical sensation that something is coming up the esophagus. Many people incorrectly equate any discomfort between the xiphoid process and umbilicus with heartburn. But heartburn isn't consistently below the xiphoid, and it usually doesn't spread out across the chest or radiate to an extremity. Nor is it predictably associated with physical activity, although it can be. It isn't constant. In most people, heartburn seldom lasts beyond a few minutes.

Rao: So, we look for a burning sensation rising up in the chest. Typically it is associated with meals; sometimes it occurs at night. Regurgitation, as you pointed out, is a separate symptom. This description fits the case study that can be a starting point for our discussion.

CASE STUDY

Jay is a 43-year-old accountant who has had persistent heartburn during the previous 2 months. He experiences symptoms 3 times per week, usually a short time after evening meals but occasionally after going to bed. He describes a burning sensation originating in his epigastrium and rising upward. He does not experience regurgitation of acid or other stomach contents. He has tried antacids with partial relief. Jay reports no abdominal pain, nausea, vomiting, change in bowel habits or stool, cough, weight loss, or other symptoms. He has no significant medical history. He smokes approximately 1 pack of cigarettes per day. He does not drink alcohol. Apart from antacids, Jay takes no prescription or over-the-counter (OTC) medications, herbs, or supplements.

Physical examination reveals a pleasant gentleman who looks his stated age. He is 5'10" and weighs 215 lb. Results of pulmonary and cardiovascular examinations are normal. On abdominal examination he has normal bowel sounds, no tenderness, and no organomegaly.

DISCUSSION POINT 2

TREATMENT GOALS

Rao: When we treat heartburn, what do we hope to achieve?

Wright: We should attempt to decrease the frequency and severity of heartburn and improve each patient's quality of life. However, it may not be possible to eliminate every episode of heartburn. (1,2)

Rao: I agree. The general goal should be to improve overall quality of life. Many people, for example, report nocturnal symptoms. Of those patients, 75% report it affects their ability to sleep, and 40% believe it impairs their ability to function the next day. (3)

Davis: We also want to prevent complications. Without appropriate treatment, erosive esophagitis and stricture formation may occur. (4)

Peura: When recommending and explaining treatment to patients, we need to make a distinction between symptom improvement and total symptom relief. So many people are dissatisfied with their heartburn treatment. (1,5) Part of the problem is that patients' expectations for treatment have been increased considerably. Also, people often diagnose themselves, self-medicate for conditions they don't have, and find that they're not getting better. They may be unaware that they've chosen an inappropriate treatment that may temporarily improve their symptoms but will not offer complete symptom relief.

Rao: I think we would offer more appropriate treatment if we just took the time to ask more specifically about what the patient is experiencing. It's imperative to take just a few seconds to ask about specific symptoms. This can help distinguish heartburn from "dyspepsia" or other conditions.

DISCUSSION POINT 3

FREQUENT HEARTBURN AND GERD

Rao: Today's discussion will focus on frequent heartburn, as opposed to episodic heartburn. Approximately 54 million adult Americans, or 26% of the population, have frequent heartburn (6) According to the US Food and Drug Administration, frequent heartburn is that which occurs 2 or more days a week.

Davis: Several of my patients have diagnosed themselves as having GERD, based on 1 main complaint: frequent heartburn.